Biltmore Psychology Services, PLLC Robin Potter, Psy.D., Licensed Clinical Psychologist 3747 North 24 th Street Phoenix, AZ 85016 Phone: 602-430-2337 Office Policies and Statement of Informed Consent Objectives of Counseling: The major goal is to help you identify and cope more effectively with problems in daily living and to deal with inner conflicts that may disrupt your ability to function effectively. This purpose is accomplished by: 1. Increasing personal awareness. 2. Increasing personal responsibility and acceptance to make changes necessary to attain your goals. 3. Identifying personal treatment goals. 4. Promoting psychological healing and emotional well-being. You are responsible for providing necessary information to facilitate effective treatment. You are expected to play an active role in your treatment, including working with Dr. Potter to outline your treatment goals and assess your progress. There may also be negative consequences if you do not follow through with recommended treatment(s). You may be asked to complete questionnaires or to do homework assignments. Your progress in therapy often depends much more on what you do between sessions than on what happens in the session. Risks of Therapy: The therapeutic process can be a very emotional experience. It is common to experience uncomfortable emotions such as sadness, fear, or frustration during the course of your therapy. These emotions can vary in degree, depending on the nature of your difficultly. While Dr. Potter cannot remove these feelings for you, she will help you work through them. In most cases these feelings are a normal part of the growth process. It is important that you take the responsibility to discuss any discomfort you feel with Dr. Potter. Appointments: Appointments are usually scheduled for 1 hour (60 minutes). Longer appointments can be scheduled according to the client(s) needs. Clients are generally seen weekly or more/less frequently as acuity dictates and you and your therapist agree. You may discontinue treatment at any time. Fees: Payment is due at the time of service. Dr. Potter s fee for services is $200/hour for a 60-minute session. Please be advised that you are billed based on the duration of the session and that longer sessions, therefore, will be billed at the same rate of $215/per hour (e.g., 1.25 hours = 250, 1.50 hours = $300). If you have no out-of-network insurance benefits, a sliding fee scale will be discussed for all veterans and military personnel. If you have out-of-network benefits, your insurance may reimburse you for a portion of this fee. If you do have this type of coverage, you must still pay at the time of service and you will be responsible for pursuing any reimbursement from your insurance. Upon request, Biltmore Psychology Services will provide you with a receipt for services for you to submit to your insurance. If you have no insurance coverage at all, Biltmore Psychology Services does have a sliding fee scale based on family size and income. You may pay with cash, check, or credit card (Visa, Master Card, & Discover). Upon scheduling your first appointment, you will be required to give your credit card information and agree to authorize Biltmore Psychology Services to charge that card for your sessions in the event that other payment has not been made at the time of service, or in the event of late cancellation or missed session that was not cancelled prior to 24 hr notice. Phone Contact is billed at the same rate as face-to-face sessions. There is no charge for phone calls lasting 10 minutes or less. Client s Initials
Cancellations and Missed Appointments: Please be aware that you may leave a message to cancel your appointment 24hrs a day. As long as you cancel your appointment at least 24 hours in advance from the time your appointment was scheduled, you will not be charged. However, you will be billed the full session fee of $180 for any cancellations made in less than 24 hours prior to your scheduled appointment. Please be aware that insurance generally does not reimburse clients for missed or late-cancelled appointments. Unpaid Balances: Please be aware that Dr. Potter will be unable to continue seeing you for scheduled sessions once you accrue an overdue balance of $250 or more, or if you no-show three consecutive sessions. Your file will be closed and a letter notifying you of this will be sent to the address listed on your intake paperwork. Emergencies: If the emergency is life threatening (dangerous to you or anyone else) CALL 911. If it is a non-life threatening emergency, you may call Dr. Potter and she will speak with you by phone and/or schedule an emergency session with you if you need her to. If you are unable to reach Dr. Potter, you may call your primary care physician, the local emergency room, or the crisis hotline: EMPACT 602 222-9444 Record Keeping: A clinical chart is maintained describing your condition, your treatment, progress in treatment, dates & fees for sessions, and notes describing each therapy session. Your records will not be released without your written consent, unless in those situations as outlined in the Confidentiality section of this document. Your records are stored in a secured manner to protect your confidentiality. You may receive a copy of your records if you make a formal written request to Biltmore Psychology Services and pay a $25 retrieval fee. Please be advised that it may take up to 10 days to receive your records from the day your request is received. If Dr. Potter determines it would not clinically be in the client s best interest to receive the complete records, a summary of the notes will be provided instead. Treatment of Minors: Biltmore Psychology Services does provide counseling to minors, defined to be individuals under the age of 18. If a parent/legal guardian is bringing the child in for services, the written consent of both parents or legal guardians is required except as otherwise determined by law. Additional documentation of guardianship might need to be provided in certain circumstances, such as divorce, before treatment can begin. Confidentiality: Issues discussed in therapy are important and are generally legally protected as both confidential and privileged. However, there are limits to the privilege of confidentiality. These situations include: 1.Suspected abuse or neglect of a child 2.Sexual activity between a minor and any person age 18 years or older 3. When your psychiatrist or therapist believes you are in danger of harming yourself or another person or you are unable to care for yourself. 4. If you report that you intend to physically injure someone. 5. If your therapist is ordered by a court to release information as part of a legal involvement. 6. When your insurance company is involved, e.g. in filing a claim, insurance audits, case review or appeals, etc. 7. In natural disasters whereby protected records may become exposed. 8. When otherwise required by law. In the event that you would like Dr. Potter to speak with other health professionals or to family members, you will be required to complete a Release of Information form in order for them to do so. In the event that you disclose to Dr. Potter that you or someone you know is abusing a child or there exists sexual activity between a minor and any person age 18 or older, she is required by law to make a report to either Arizona Child Protective Services or the police. In the event that you disclose information to Dr. Potter that leads her to believe that you are a danger to yourself or others and you are unwilling to voluntarily admit yourself to inpatient care (hospital or other treatment facility), she is required to contact a psychiatric facility or hospital to file the appropriate papers for an involuntary admission for treatment. This is to ensure safety for yourself and others and ensure you receive appropriate medical treatment.
Initials Client s Confidentiality Continued: In the event that you disclose to Dr. Potter that you are a danger to others, she is required by law to report you to the police and potential victim(s). THERE WILL BE NO EXCEPTIONS MADE TO THESE POLICIES, AS THEY ARE MANDATED BY LAW. Scope of Practice: Dr. Potter at Biltmore Psychology Services has limited availability. She is not on call, nor do she have an emergency staff for after-hours treatment. Persons who may be in need of immediate care, or are frequently in crisis, will need more availability than Dr. Potter at Biltmore Psychology Services is able to provide. Certain conditions and diagnoses are also not within the scope of Dr Potter s expertise (e.g., severe mental illness). Given the nature and scope of her practice, Dr. Potter at Biltmore Psychology Services reserves the right not to treat persons with certain diagnoses or treatment histories, such as those listed below. She will, however, assist you by referring to professionals who can better serve your treatment needs. Any Severe Mental Illness: (including but not limited to Schizophrenia, and Disassociative Identity Disorder) Anti-Social, Paranoid, Schizotypal or Dependent Personality Disorders The following circumstances will also warrant termination of services based on Dr. Potter s assessment of the client s treatment needs and if it is in the client s best interest to receive a higher level of care and/or more highly specialized treatment: * Failure to disclose History of Prior Hospitalization or in-patient treatment for mental health issues (e.g., suicide attempt, eating disorder, substance abuse). *Failure to Disclose Ongoing Substance Abuse *Current Involvement with any Illegal Activity By signing this agreement, you are stating that you have never been diagnosed with any of the disorders listed as being outside the scope of practice (the above list) and that you have never been hospitalized or participated in inpatient treatment at any time in your life. Consent for Treatment By signing below, you are stating that: 1) You have read and understood this 3-page policy statement. 2) You have had your questions answered to your satisfaction. I accept, understand, and agree to abide by the contents and terms of this agreement. Further, I consent to participate in evaluation and/or treatment. I understand that I may withdraw from treatment at any time Client s Printed Name: Client s Signature: Date: (Or GUARDIAN if client is a minor) Therapist s Signature: Date:
Biltmore Psychology Services, PLLC Robin Potter, Psy.D., Licensed Clinical Psychologist 3747 North 24 th St Phoenix, AZ 85016 602-430-2337 Client Information Name:, last first middle Initial Date of Birth: / / Email: month day year Address: street address city state Zip code Home Phone: Work Phone: Cell Phone: Emergency Contact: Relationship to emergency contact: I UNDERSTAND THAT DR. POTTER IS NOT A PROVIDOR FOR ANY GOVERNMENT OR PRIVATE MEDICAL AND/OR MENTAL HEALTH COVERAGE, INCLUDING, BUT NOT LIMITED TO, MEDICARE AND MEDICAID. BY SIGNING BELOW, I ACKNOWLEDGE THAT: 1) I HAVE BEEN INFORMED OF THIS POLICY 2) I AM DECLARING THAT I DO NOT HAVE MEDICARE OR MEDICAID OR ANY OTHER GOVERNMENT HEALTHCARE COVERAGE 3) I KNOW THAT DR. POTTER S RATE IS $200 PER HOUR AND I AGREE TO PAY THIS RATE. 4) IN THE EVENT THAT THE SESSION LASTS LONGER THAN THE ORIGINALLY SCHEDULED TIME PERIOD, I AGREE TO PAY THE FULL AMOUNT OF THE TIME USED FOR THE SESSION AT A RATE OF $45 PER 15 MINUTES OF ADDITIONAL TIME SIGNATURE: DATE: I authorize the following credit card to be on file and for Biltmore Psychology Services to charge this credit card for the above-stated rate according to the amount of time scheduled for my appointment for the following circumstances: 1) services received for which other payment has not already been made 2)appointments that I miss or cancel within less than 24 hours of my scheduled time. I also authorize a fee of $35 to be charged to this card under the following circumstances: 1) Check payment returned due to insufficient funds 2) if credit card on file is declined when payment processed 3) failure to return book(s) ($35 per book) borrowed from Dr. Potter within 30 days of receipt of written request that a book be returned). Credit Card Type: Visa MasterCard Discover Name as it appears on the card: Credit Card Number: Expiration Date: / / Month Day Year CVC Code (3-digit code on back of card: Client s Printed Name: Client s Signature Date
Biltmore Psychology Services, PLLC Robin Potter, Psy.D., Licensed Clinical Psychologist 3747 North 24 th Street Phoenix, AZ 85016 602-430-2337 Consent to use and disclose your health information NOTE: We will not send any of your information to other health care/mental health care providers without your specific consent unless there is a duty to warn issue as stated in the office policy forms. This form is required to store your information in encrypted electronic files. Again we do not bill directly to insurance companies, we can provide you a superbill that you submit directly to your insurance company. This form is an agreement between you,, and Biltmore Psychology Services, PLLC. When we refer to the word you, it can apply to you, your child, a relative, or other person if the name is written here. When we examine, test, diagnose, treat, provide services, or refer you to another provider, we will be collecting what the law refers to as Protected Health Information (PHI). We will use this information to decide on treatment/services to provide and to be able to provide you treatment/services. We are also able to use and share this information with others who provide you treatment or to arrange payment for the treatment/services we provide or other business/government functions. (Insurance Companies) By signing below, you agree to let us use this information here and send it to others. The Notice of Privacy Practices explains in more detail your privacy rights and how we can use and disclose your information. Please make sure to read this notice before signing this Consent form. If you do not sign this consent form agreeing to what is in our Notice of Privacy Practices, we cannot treat you In the future, we may change how we use and share your information so we may change our Notice of Privacy Practices. If we do so, we will provide you an updated copy. If you are concerned about some of your information, you have the right to ask us not to share some of your information for treatment, payment, or administrative purposes and will need to tell us what you want in writing. We will try to accommodate your requests; however, we are not required to agree to these limitations, but if we do agree, we will honor our agreement unless we are unable to by law. After you have signed this request, you can revoke your consent by writing a letter to our Privacy Officer Dr. Robin Potter, informing us of your wishes. We will comply with your request from that point forward but will be unable to change or revoke the information that has already been shared. Please be aware that if you revoke your consent, we will be unable to continue providing treatment or services to you. Signature of client or personal representative Date Signature of client or personal representative Date Relationship to client/description of personal representative s authority Signature of authorized representative of this practice Date of NPP
Social Media Policy This document outlines office policies related to the use of Social Media. Please read it to understand how we conduct ourselves on the Internet as mental health professionals and how you can expect us to respond to various interactions that may occur between us on the internet. If you have any questions about anything within this document, you are encouraged to bring them up when we meet. As the technology develops and the Internet changes, there may be times when this policy will be updated. If the policy changes, you will be notified in writing of any policy changes and make sure you have a copy of the updated policy. Friending I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc.). By adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have any questions about this, please bring them up when we meet and we can talk more about it. Interacting Please do not use SMS messaging on Social Networking sites such as Twitter, Facebook, or LinkedIn to contact me. These sites are not secure and I may not read these messages in a timely fashion. Do not use Wall postings, @replies, or other means of engaging with me in public online if we have an already established client/therapist relationship. Engaging with me this way could compromise your confidentiality. It may also create the possibility that these exchanges become a part of your legal medical record and will need to be documented and archived in your chart. If you need to contact me between sessions, the best way to do so is by phone. Directemail with your provider is second best for quick, administrative issues such as changing appointment times. See the email section below for more information regarding email interactions. Use of Search Engines It is NOT a regular part of my practice to search for clients on Google or Facebook or other search engines. Extremely rare exceptions may be made during times of crisis. If I have a reason to suspect that you are in danger and you have not been in touch with me via our usual means (coming to appointments, phone, or email) there might be an instance in which using a search engine (to find you, find someone close to you, or to check on your recent status updates) becomes necessary as part of ensuring your welfare. These are unusual situations and if I ever resort to such means, I will fully document it and discuss it with you when we next meet. Google Reader I do not follow current or former clients on Google Reader and I do not use Google Reader to share articles. If there are things you want to share with me that you feel are relevant to your treatment whether they are news items of things you have created, I encourage you to bring these items of interest into our sessions. Business Review Sites You may find my psychology practice on sites such as Yelp, Healthgrades, Yahoo Local, Bing, or other places which list businesses. Some of these sites include forums in which users rate their providers and add reviews. Many of these comb search engines for business listings and automatically add listening regardless of whether the business has added itself to the site. If you should find my listing on any of these sites, please know that my listing is NOT a request for a testimonial, rating, or endorsement from you as my client. The American Psychological Association s Ethics Code states under Principle 5.05 that it is unethical for psychologist to solicit testimonials: Psychologists do not solicit testimonials from current therapy clients/patients or other persons who because of their particular circumstances are vulnerable to undue
influences. Of course, you have a right to express yourself on any site you wish. But due to confidentiality, I cannot respond to any review on any of these sites whether it is positive or negative. I urge you to take your own privacy as seriously as I take my commitment of confidentiality to you. You should also be aware that if you are using these sites to communicate indirectly with me about your feelings about our work, there is a good possibility that I may never see it. If we are working together, I hope that you will bring your feelings and reactions to our work directly into the therapy process. This can be an important part of therapy, even if you decide we are not a good fit. None of this is meant to keep you from sharing that you are in therapy with me whenever and with whomever you like. Confidentiality means that I cannot tell people that you are my client and my Ethics Code prohibits me from requesting testimonials. That said, you are more than welcome to tell anyone you wish that I m your therapist or how you feel about the treatment I provided to you, in any forum of your choosing. If you do choose to write something on a business review site, I hope you will keep in mind that you may be sharing personally revealing information in a public forum. I urge you to create a pseudonym that is not linked to your regular email address or friend networks for your own privacy and protection. If you feel I have done something harmful or unethical and you do not feel comfortable discussing it with me, you can always contact the Arizona Board of Psychology Examiners (602-542-8161), which oversees licensing, and they will review the services I have provided. Location-Based Services If you used location-based services on your mobile phone, you may wish to be aware of the privacy issues related to using these services. I do not place my practice as a check-in location on various sites such as Foursquare, Gowalla, Loopt, etc. However, if you have GPS enabled on your device, it is possible to surmise that you a therapy client due to regular check-ins at my office on a weekly basis. Please be aware of this risk if you are intentionally checking in, from my office or if you have a passive LBS app enabled on your phone. Email I prefer using email to arrange or modify appointments. Please do not email me content related to your therapy sessions, as emails is not completely secure or confidential. If you choose to communicate with me by email, be aware that all emails are retained in the logs of your and my internet service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider. You should also know that any emails I receive from you and any responses that I send to you become a part of your legal record. Conclusion Thank you for taking the time to review my Social Media Policy. If you have any questions or concerns about any of these policies and procedures or regarding our potential interactions on the Internet, do bring them to my attention so that we can discuss them. Client signature Client Signature Therapist signature Date